Pain Relief Interventions

According to the National Institute on Drug Abuse, "Every day, more than 130 people in the United States die after overdosing on opioids. The misuse of and addiction to opioids—including prescription pain relievers, heroin, and synthetic opioids such as fentanyl—is a serious national crisis that affects public health as well as social and economic welfare". The unnecessary prescription and misuse of opioids has led to the "opioid overdose crisis" evident in today's society (National Institute on Drug Abuse, 2019). This epidemic began in the late 1990s when it was believed by pharmaceutical companies that prescription opioid pain relievers had limited to no addictive properties and were safe for widespread use (National Institute on Drug Abuse, 2019). As a result, opioids were prescribed at much greater rates leading to widespread diversion and misuse of the medications (National Institute on Drug Abuse, 2019). Opioid overdose rates began to climb while prescription opioids continued to be distributed widespread (National Institute on Drug Abuse, 2019). "In 2017, more than 47,000 Americans died as a result of an opioid overdose, including prescription opioids, heroin, and illicitly manufactured fentanyl, a powerful synthetic opioid. That same year, an estimated 1.7 million people in the United States suffered from substance use disorders related to prescription opioid pain relievers” (National Institute on Drug Abuse, 2019).

It is because of this widespread opioid epidemic that alternative pain relief interventions have grown increasingly popular. These alternative interventions are known as non-pharmacological interventions and include techniques such as massage, music therapy, guided imagery, deep breathing, distraction, and acupuncture. In an attempt to eliminate opioid dependence and addiction, non-pharmacological interventions have erupted and become utilized widespread. These interventions can be utilized to complement pharmacological interventions or, in some instances, replace these interventions.

Pharmacological interventions include over-the-counter medications such as non-steroidal anti-inflammatory medications including ibuprofen and acetaminophen. Pharmacological interventions also include prescription opioid medications including morphine, oxycodone, codeine, and fentanyl. Many of these prescription medications result in immense adverse effects and can even result in dependence and addiction, as described above.

Through this literature review, the question I am attempting to answer is in patients experiencing pain, do non-pharmacological interventions compared to pharmacological interventions elicit a better pain relief response. I will answer this question by utilizing and evaluating current evidence-based practice literature regarding pain relief interventions coupled with an extensive evaluation and systematic review of the various techniques and their effectiveness. Throughout this literature review, both non-pharmacological and pharmacological interventions will be identified and evaluated in an attempt to establish the best interventions to relieve pain.

The National Institute on Drug Abuse identifies this issue as being "a public health crisis with devastating consequences including increases in opioid misuse and related overdoses" (National Institute on Drug Abuse, 2019). The following statistics and diagram have been provided by the National Institute on Drug Abuse to outline the year-to-year increase in opioid dependence from 2016 to 2017 in the United States.

• Increase in opioid overdoses of 30% between July 2016 and September 2017 across 45 states (National Institute on Drug Abuse, 2019)
• Increase in opioid overdoses of 70% between July 2016 and September 2017 in the Midwestern region (National Institute on Drug Abuse, 2019)
• Increase in opioid overdoses in large cities of 54% across 16 states (National Institute on Drug Abuse, 2019).As mentioned before, non-pharmacological interventions have erupted and become utilized widespread in an attempt to eliminate opioid dependence and addiction. Through thorough analysis of the current literature and evidence-based practice guidelines regarding the utilization of non-pharmacological interventions, the following has been evaluated and concluded.

The effects of non-pharmacological interventions for pain relief have been evaluated in various situations including neonates, paramedicine, emergency setting, and labor and delivery. According to the article titled "Nonpharmacological Interventions for Pain Management in Paramedicine and the Emergency Setting: A Review of the Literature", paramedic medicine has historically focused on pharmacological interventions for the alleviation of pain, however, emerging research has emphasized the incorporation of nonpharmacological interventions for pain management in this setting. The article further identifies nonpharmacological interventions as including techniques such as acupuncture and acupressure, transcutaneous electrical nerve stimulation (TENS), and physical therapies including massage, chiropractic interventions, and hot/cold applications; psychological interventions such as distraction, hypnosis, and stress management are also addressed (Pak, Micalos, Maria, & Lord, 2015). The article continues on to evaluate the utilization of these techniques in the emergency setting and identifies the use of these nonpharmacological therapies specifically in the treatment of chronic pain (Pak et al., 2015). This article further acknowledges and addresses the lack of research into these utilizing these interventions for acute pain (Pak et al., 2015).

Upon evaluation of this article, it was concluded that “Even though paramedic practice is firmly focused on pharmacological interventions to alleviate pain, there is a developing literature suggesting that a range of nonpharmacological options may also have an important role in managing pain in individuals cared for by paramedics” (Pak et al., 2015). Therefore, this article lends its support to the practicality of utilizing a combination of non-pharmacological and pharmacological interventions for the treatment and alleviation of pain.

The article “Non-Pharmacological Strategies for Addressing Infant Pain” discusses the utilization of non-pharmacological interventions for infants and neonates. Four non-pharmacological interventions are identified in this article including oral sucrose, breastfeeding, holding/tucking/swaddling, and attention modification such as distraction as being ideal for treating infant pain as well as supported by current research (Boles, 2017). It is recommended that these interventions be used in conjunction with pain relief medications in order to provide the most effective pain relief measures for this population (Boles, 2017). The article continues on to state, “Oral sucrose, breastfeeding, holding or swaddling, and distraction have proven to be useful methods for helping infants manage painful experiences. The common thread between these interventions is that they address the infant’s primary developmental goals and needs through the senses of taste, touch, smell, sight, and sound” (Boles, 2017). Management of pain in this population is vitally important due to their inability to effectively communicate their needs and pain. This article supports the consensus thus far that the combination of non-pharmacological interventions with pharmacological interventions is the best approach to effectively managing and alleviating pain in this population. The utilization of non-pharmacological interventions in this scenario allows for a reduction in the amount of pain medications required to alleviate the pain.

The article “A computational strategy for finding novel targets and therapeutic compounds for opioid dependence” addresses the magnitude of opioid dependence in the United States and focuses on the importance of developing adequate treatment for sufferers of this addiction. According to the article, “Despite that opioids have beneficial analgesic effects of alleviating acute and chronic pain, chronic opioid use can lead to adverse side effects including tolerance, hyperalgesia, withdrawal reactions, and even dependence. In order to achieve optimal pain management, many studies have been carried out to elucidate mechanisms underlying both the beneficial as well as the adverse effects of opioid” (Wu, Xie, Wang, Fan, Ge, Xie, & Wu, 2018). Opioid dependence and addiction is detrimental to all persons involved and affected. Morphine and heroin were the primary focus for the purposes of this article and it was concluded that the prolonged use of these substances can lead to behavioral and personality changes related to the physical changes occurring in the brain (Wu et al., 2018). Opioids have the ability to enhance or reduce transcription factor expression in the neuronal pathways as well as alter gene transcription and “induce addiction by epigenetic mechanisms” (Wu et al., 2018). Further research is available regarding the specific neurological consequences of prolonged opioid use, however, for the purposes of this paper, the behavioral and personality changes resulting directly from extensive usage of these substances will be sufficient to supplement and support our research.

Upon thorough evaluation of the articles afore mentioned as well as current evidence-based practice literature, non-pharmacological interventions are effective in the treatment and alleviation of pain in various scenarios. Non-pharmacological interventions such as massage, music therapy, guided imagery, deep breathing, distraction, and acupuncture have been tested and evaluated in various situations including neonates, paramedicine, and the emergency setting, as mentioned above. These environments all produced similar results in that non-pharmacological interventions were shown to be effective in the management of pain, however, it was recommended that these interventions be used in combination with pharmacological approaches instead of stand-alone. The coupling of pharmacological interventions with non-pharmacological interventions provides a unique opportunity for pain management in that the pharmacological methods have been proven extremely effective in pain management and the addition of non-pharmacological interventions allows for a reduction in the dosage of pain medications. Pharmacological interventions such as prescription opioid medications can be highly addictive and lead to dependence and addiction. The addition of non-pharmacological therapies to pain management allows for a lower dosage of opioid medications to be prescribed in an attempt to diminish the likelihood of addiction and dependence. The movement towards non-pharmacological pain management is rapidly growing and spreading nationwide. While non-pharmacological therapies may not completely replace pharmacological methods at this time, utilizing a combination of both types of interventions is a step in the right direction and will hopefully result in and lead to a reduction in the rate of addiction and number of deaths from opioid overdose.

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